Cycle 1
Health 2025-07-02 · Fire 2025-07-02
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Malvern, AR
Arbor Oaks Healthcare And Rehabilitation Center
4-star overall rating with 4-star inspections with $8,018 in total fines with 4 recent health deficiencies
955 Division, Malvern, AR
(501) 332-5251
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
94
Certified beds
Average residents
64
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Southern Administrative Services
Operator or chain grouping
Approved since
1995-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
35 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.43
Registered nurse staffing · state 0.40 · national 0.68
LPN hours / resident day
1.20
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.72 · national 2.35
Total nurse hours
3.73
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.35 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.48 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.27 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
4.02
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 51% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,684
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.86% · Performance 21.40% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.80
Baseline 6.98% · Performance 7.30% · Measure score 1.80 · Achievement 1.80 · Improvement 0
Total nurse turnover
3.02
Baseline 53.23% · Performance 51.35% · Measure score 3.02 · Achievement 3.02 · Improvement 0.16
Adjusted total nurse staffing
2.98
Baseline 3.84 hours · Performance 3.93 hours · Measure score 2.98 · Achievement 2.98 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.94% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 16.95% · Lower 95% interval 7.89% |
| Discharge to community | 45.25% |
50.57%
5.3 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 37.5% · Lower 95% interval 32.82% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 65% |
95.27%
30.3 pts worse
|
Numerator 26 · Denominator 40 |
| Falls with major injury | 7.5% |
0.77%
6.7 pts worse
|
Numerator 3 · Denominator 40 |
| Discharge self-care score | 60.61% |
53.69%
6.9 pts better
|
Numerator 20 · Denominator 33 |
| Discharge mobility score | 60.61% |
50.94%
9.7 pts better
|
Numerator 20 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 5% |
2.29%
2.7 pts worse
|
Numerator 2 · Denominator 40 · Adjusted rate 4.49% |
| Healthcare-associated infections requiring hospitalization | 7.3% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 8.11% · Lower 95% interval 3.95% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 64 |
| Staff flu vaccination coverage | 92.86% |
42%
50.9 pts better
|
Numerator 78 · Denominator 84 |
| Discharge function score | 54.55% |
56.45%
1.9 pts worse
|
Numerator 18 · Denominator 33 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 23 · Denominator 23 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.0
0.3 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.0 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.8 |
2.2
1.6 pts worse
|
1.8
2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 3.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
94.9%
3.7 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 98.2% · Q3 98.1% · Q4 100.0% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.3% |
3.9%
3.4 pts worse
|
3.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 7.0% · Q3 5.8% · Q4 9.6% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
1.4%
1.4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 6.9% |
4.9%
2 pts worse
|
5.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 7.4% · Q3 10.6% · Q4 2.2% · 4Q avg 6.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.4% |
21.8%
3.6 pts worse
|
19.6%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 30.9% · Q3 21.3% · Q4 19.6% · 4Q avg 25.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.0% |
12.5%
4.5 pts better
|
16.7%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 8.7% · Q3 7.3% · Q4 9.3% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.7% |
11.4%
1.7 pts better
|
16.3%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 4.9% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.3% |
10.4%
4.1 pts better
|
14.9%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 11.8% · Q3 4.7% · Q4 2.4% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.7%
0.2 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 1.8% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.1%
1.1 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.8% |
14.6%
0.8 pts better
|
19.8%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.4% · Q2 13.2% · Q3 12.8% · Q4 17.0% · 4Q avg 13.8% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
4.6%
1.3 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 8.6% · Q3 7.2% · Q4 4.5% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
81.8%
13.2 pts better
|
81.7%
13.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.5% · Q2 98.0% · Q3 96.9% · Q4 92.6% · 4Q avg 95.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
13.8%
2.9 pts better
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 11.6% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.4%
1.4 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.0% |
77.9%
20.1 pts better
|
79.7%
18.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.8% |
25.2%
1.6 pts worse
|
23.9%
2.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.8% · Observed 27.9% · Expected 24.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-27 · Fire 2024-06-27
6 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-07-28 · Fire 2023-07-28
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-27
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-07-19
F · Potential for more than minimal harm
2023-07-28
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-07-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-02
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2025-07-25
C · Minimal harm
2025-07-02
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-06-19
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-11
G · Actual harm
2024-06-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-06-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-06-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-06-27
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-06-27
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-06-27
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-08-06
F · Potential for more than minimal harm
2023-07-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-07-28
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-07-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-07-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-07-28
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-07-28
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-07-28
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-28
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-03-07
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-04-06
Penalties and ownership
What sits behind the stars
$8,018
2024-06-27
Fine
Fine · fine $8,018
Fine
$0
2024-06-27
Payment Denial
Payment Denial · denial start 2024-07-26 · 11 days
11 day denial
Ownership
4p2t1 Ops Holding LP
5% Or Greater Direct Ownership Interest · Organization
Alexark1 LLC
General Partnership Interest · Organization
Jej Assets LP
5% Or Greater Indirect Ownership Interest · Organization
Jej Management, LLC
General Partnership Interest · Organization
Ponthie, John
5% Or Greater Indirect Ownership Interest · Individual
Ponthie, John
Corporate Officer · Individual
Ponthie, Sharlot
5% Or Greater Indirect Ownership Interest · Individual
Worthington, Chyra
Operational/Managerial Control · Individual
Nearby options
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Encore Healthcare And Rehabi Of Malvern
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2-star overall rating with 2-star inspections with 9 recent health deficiencies
#2
The Pines Nursing And Rehabilitation Center
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3-star overall rating with 3-star inspections with $13,863 in total fines with 4 recent health deficiencies
#3
The Springs Of Red Oak
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3-star overall rating with 3-star inspections with $14,935 in total fines with 8 recent health deficiencies
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